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| My eyes at the moment of the apparitions by August Natterer, a German artist who created many drawings of his hallucinations. |
A hallucination is a perception in the absence of external stimulus that has qualities of real perception. Hallucinations are vivid, substantial, and are perceived to be located in external objective space. They are distinguishable from several related phenomena, such as dreaming, which does not involve wakefulness; pseudohallucination, which does not mimic real perception, and is accurately perceived as unreal; illusion, which involves distorted or misinterpreted real perception; and imagery (imagination), which does not mimic real perception and is under voluntary control. Hallucinations also differ from "delusional perceptions", in which a correctly sensed and interpreted stimulus (i.e., a real perception) is given some additional (and typically absurd) significance.
Hallucinations can occur in any sensory modality—visual, auditory, olfactory, gustatory, tactile, proprioceptive, equilibrioceptive, nociceptive, thermoceptive and chronoceptive.
A mild form of hallucination is known as a disturbance, and can occur in most of the senses above. These may be things like seeing movement in peripheral vision, or hearing faint noises or voices. Auditory hallucinations are very common in schizophrenia. They may be benevolent (telling the subject good things about themselves) or malicious, cursing the subject, etc. Auditory hallucinations of the malicious type are frequently heard, for example people talking about the subject behind their back. Like auditory hallucinations, the source of the visual counterpart can also be behind the subject's back. Their visual counterpart is the feeling of being looked or stared at, usually with malicious intent. Frequently, auditory hallucinations and their visual counterpart are experienced by the subject together.
Hypnagogic hallucinations and hypnopompic hallucinations are considered normal phenomena. Hypnagogic hallucinations can occur as one is falling asleep and hypnopompic hallucinations occur when one is waking up. Hallucinations can be associated with drug use (particularly deliriants), sleep deprivation, psychosis, neurological disorders, and delirium tremens.
The word "hallucination" itself was introduced into the English language by the 17th-century physician Sir Thomas Browne in 1646 from the derivation of the Latin word alucinari meaning to wander in the mind. For Browne, hallucination means a sort of vision that is "depraved and receive[s] its objects erroneously".
Classification
Hallucinations may be manifested in a variety of forms.
Various forms of hallucinations affect different senses, sometimes
occurring simultaneously, creating multiple sensory hallucinations for
those experiencing them.
Visual
A visual hallucination is "the perception of an external visual stimulus where none exists". A separate but related phenomenon is a visual illusion, which is a distortion of a real external stimulus. Visual hallucinations are classified as simple or complex:
- Simple visual hallucinations (SVH) are also referred to as non-formed visual hallucinations and elementary visual hallucinations. These terms refer to lights, colors, geometric shapes, and indiscrete objects. These can be further subdivided into phosphenes which are SVH without structure, and photopsias which are SVH with geometric structures.
- Complex visual hallucinations (CVH) are also referred to as formed visual hallucinations. CVHs are clear, lifelike images or scenes such as people, animals, objects, places, etc.
For example, one may report hallucinating a giraffe. A simple visual
hallucination is an amorphous figure that may have a similar shape or
color to a giraffe (looks like a giraffe), while a complex visual hallucination is a discrete, lifelike image that is, unmistakably, a giraffe.
Auditory
Auditory hallucinations (also known as paracusia) are the perception of sound without outside stimulus. Auditory hallucinations are the most common type of hallucination.
Auditory hallucinations can be divided into two categories: elementary
and complex. Elementary hallucinations are the perception of sounds such
as hissing, whistling, an extended tone, and more. In many cases, tinnitus
is an elementary auditory hallucination. However, some people who
experience certain types of tinnitus, especially pulsatile tinnitus, are
actually hearing the blood rushing through vessels near the ear.
Because the auditory stimulus is present in this situation, it does not
qualify it as a hallucination.
Complex hallucinations are those of voices, music, or other
sounds that may or may not be clear, may be familiar or completely
unfamiliar, and friendly or aggressive, among other possibilities. A
hallucination of a single individual person of one or more talking
voices is particularly associated with psychotic disorders such as schizophrenia, and hold special significance in diagnosing these conditions.
Another typical disorder where auditory hallucinations are very common is dissociative identity disorder.
In schizophrenia voices are normally perceived coming from outside the
person but in dissociative disorders they are perceived as originating
from within the person, commenting in their head instead of behind their
back. Differential diagnosis between schizophrenia and dissociative disorders is challenging due to many overlapping symptoms, especially Schneiderian first rank symptoms such as hallucinations. However, many people not suffering from diagnosable mental illness may sometimes hear voices as well. One important example to consider when forming a differential diagnosis for a patient with paracusia is lateral temporal lobe epilepsy. Despite the tendency to associate hearing voices, or otherwise hallucinating, and psychosis
with schizophrenia or other psychiatric illnesses, it is crucial to
take into consideration that, even if a person does exhibit psychotic
features, he/she does not necessarily suffer from a psychiatric disorder
on its own. Disorders such as Wilson's disease, various endocrine diseases, numerous metabolic disturbances, multiple sclerosis, systemic lupus erythematosus, porphyria, sarcoidosis, and many others can present with psychosis.
Musical hallucinations are also relatively common in terms of
complex auditory hallucinations and may be the result of a wide range of
causes ranging from hearing-loss (such as in musical ear syndrome, the auditory version of Charles Bonnet syndrome), lateral temporal lobe epilepsy, arteriovenous malformation, stroke, lesion, abscess, or tumor.
The Hearing Voices Movement
is a support and advocacy group for people who hallucinate voices, but
do not otherwise show signs of mental illness or impairment.
High caffeine consumption has been linked to an increase in likelihood of one experiencing auditory hallucinations. A study conducted by the La Trobe University
School of Psychological Sciences revealed that as few as five cups of
coffee a day (approximately 500 mg of caffeine) could trigger the
phenomenon.
Command
Command
hallucinations are hallucinations in the form of commands; they can be
auditory or inside of the person's mind or consciousness. The contents of the hallucinations can range from the innocuous to commands to cause harm to the self or others. Command hallucinations are often associated with schizophrenia.
People experiencing command hallucinations may or may not comply with
the hallucinated commands, depending on the circumstances. Compliance is
more common for non-violent commands.
Command hallucinations are sometimes used to defend a crime that has been committed, often homicides.
In essence, it is a voice that one hears and it tells the listener what
to do. Sometimes the commands are quite benign directives such as
"Stand up" or "Shut the door."
Whether it is a command for something simple or something that is a
threat, it is still considered a "command hallucination." Some helpful
questions that can assist one in figuring out if he/she may be suffering
from this include: "What are the voices telling you to do?", "When did
your voices first start telling you to do things?", "Do you recognize
the person who is telling you to harm yourself (or others)?", "Do you
think you can resist doing what the voices are telling you to do?"
Olfactory
Phantosmia (olfactory hallucinations), smelling an odor that is not actually there, and parosmia (olfactory illusions), inhaling a real odor but perceiving it as different scent than remembered, are distortions to the sense of smell (olfactory system) that, in most cases, are not caused by anything serious and usually go away on their own in time. It can result from a range of conditions such as nasal infections, nasal polyps, dental problems, migraines, head injuries, seizures, strokes, or brain tumors.
Environmental exposures are sometimes the cause as well, such as
smoking, exposure to certain types of chemicals (e.g., insecticides or solvents), or radiation treatment for head or neck cancer. It can also be a symptom of certain mental disorders such as depression, bipolar disorder, intoxication or withdrawal from drugs and alcohol, or psychotic disorders (e.g., schizophrenia). The perceived odors are usually unpleasant and commonly described as smelling burned, foul spoiled, or rotten.
Tactile
Tactile hallucinations are the illusion of tactile sensory input,
simulating various types of pressure to the skin or other organs. One
subtype of tactile hallucination, formication, is the sensation of insects crawling underneath the skin and is frequently associated with prolonged cocaine use. However, formication may also be the result of normal hormonal changes such as menopause, or disorders such as peripheral neuropathy, high fevers, Lyme disease, skin cancer, and more.
Gustatory
This
type of hallucination is the perception of taste without a stimulus.
These hallucinations, which are typically strange or unpleasant, are
relatively common among individuals who have certain types of focal epilepsy, especially temporal lobe epilepsy. The regions of the brain responsible for gustatory hallucination in this case are the insula and the superior bank of the sylvian fissure.
General somatic sensations
General
somatic sensations of a hallucinatory nature are experienced when an
individual feels that their body is being mutilated, i.e. twisted, torn,
or disembowelled. Other reported cases are invasion by animals in the
person's internal organs such as snakes in the stomach or frogs in the
rectum. The general feeling that one's flesh is decomposing is also
classified under this type of hallucination.
Cause
Hallucinations can be caused by a number of factors.
Hypnagogic hallucination
These hallucinations occur just before falling asleep, and affect a
high proportion of the population: in one survey 37% of the respondents
experienced them twice a week.
The hallucinations can last from seconds to minutes; all the while, the
subject usually remains aware of the true nature of the images. These
may be associated with narcolepsy. Hypnagogic hallucinations are sometimes associated with brainstem abnormalities, but this is rare.
Peduncular hallucinosis
Peduncular means pertaining to the peduncle, which is a neural tract running to and from the pons on the brain stem.
These hallucinations usually occur in the evenings, but not during
drowsiness, as in the case of hypnagogic hallucination. The subject is
usually fully conscious and then can interact with the hallucinatory
characters for extended periods of time. As in the case of hypnagogic hallucinations,
insight into the nature of the images remains intact. The false images
can occur in any part of the visual field, and are rarely polymodal.
Delirium tremens
One of the more enigmatic forms of visual hallucination is the highly variable, possibly polymodal delirium tremens.
Individuals suffering from delirium tremens may be agitated and
confused, especially in the later stages of this disease. Insight is
gradually reduced with the progression of this disorder. Sleep is
disturbed and occurs for a shorter period of time, with rapid eye movement sleep.
Parkinson's disease and Lewy body dementia
Parkinson's disease is linked with Lewy body dementia
for their similar hallucinatory symptoms. The symptoms strike during
the evening in any part of the visual field, and are rarely polymodal. The segue into hallucination may begin with illusions
where sensory perception is greatly distorted, but no novel sensory
information is present. These typically last for several minutes, during
which time the subject may be either conscious and normal or
drowsy/inaccessible. Insight into these hallucinations is usually
preserved and REM sleep is usually reduced. Parkinson's disease is usually associated with a degraded substantia nigra
pars compacta, but recent evidence suggests that PD affects a number of
sites in the brain. Some places of noted degradation include the median
raphe nuclei, the noradrenergic parts of the locus coeruleus, and the cholinergic neurons in the parabrachial area and pedunculopontine nuclei of the tegmentum.
Migraine coma
This type of hallucination is usually experienced during the recovery
from a comatose state. The migraine coma can last for up to two days,
and a state of depression is sometimes comorbid.
The hallucinations occur during states of full consciousness, and
insight into the hallucinatory nature of the images is preserved. It has
been noted that ataxic lesions accompany the migraine coma.
Charles Bonnet syndrome
Charles Bonnet syndrome is the name given to visual hallucinations experienced by a partially or severely sight impaired
person. The hallucinations can occur at any time and can distress
people of any age, as they may not initially be aware that they are
hallucinating, they may fear initially for their own mental health which
may delay them sharing with carers what is happening until they start
to understand it themselves. The hallucinations can frighten and
disconcert as to what is real and what is not and carers need to learn
how to support sufferers. The hallucinations can sometimes be dispersed
by eye movements, or perhaps just reasoned logic such as, "I can see
fire but there is no smoke and there is no heat from it" or perhaps "We
have an infestation of rats but they have pink ribbons with a bell tied
on their necks." Over elapsed months and years the manifestation of the
hallucinations may change, becoming more or less frequent with changes
in ability to see. The length of time that the sight impaired person can
suffer from these hallucinations varies according to the underlying
speed of eye deterioration. A differential diagnosis are ophthalmopathic
hallucinations.
Focal epilepsy
Visual hallucinations due to focal seizures differ depending on the region of the brain where the seizure occurs. For example, visual hallucinations during occipital lobe seizures are typically visions of brightly colored, geometric shapes that may move across the visual field,
multiply, or form concentric rings and generally persist from a few
seconds to a few minutes. They are usually unilateral and localized to
one part of the visual field on the contralateral side of the seizure
focus, typically the temporal field. However, unilateral visions moving horizontally across the visual field begin on the contralateral side and move toward the ipsilateral side.
Temporal lobe seizures, on the other hand, can produce complex visual hallucinations of people, scenes, animals, and more as well as distortions of visual perception.
Complex hallucinations may appear to be real or unreal, may or may not
be distorted with respect to size, and may seem disturbing or affable,
among other variables. One rare but notable type of hallucination is heautoscopy,
a hallucination of a mirror image of one's self. These "other selves"
may be perfectly still or performing complex tasks, may be an image of a
younger self or the present self, and tend to be only briefly present.
Complex hallucinations are a relatively uncommon finding in temporal
lobe epilepsy patients. Rarely, they may occur during occipital focal
seizures or in parietal lobe seizures.
Distortions in visual perception during a temporal lobe seizure may include size distortion (micropsia or macropsia),
distorted perception of movement (where moving objects may appear to be
moving very slowly or to be perfectly still), a sense that surfaces
such as ceilings and even entire horizons are moving farther away in a
fashion similar to the dolly zoom effect, and other illusions. Even when consciousness is impaired, insight into the hallucination or illusion is typically preserved.
Drug-induced hallucination
Drug-induced hallucinations are caused by hallucinogens, dissociatives, and deliriants, including many drugs with anticholinergic actions and certain stimulants, which are known to cause visual and auditory hallucinations. Some psychedelics such as lysergic acid diethylamide (LSD) and psilocybin can cause hallucinations that range in the spectrum of mild to intense.
Hallucinations, pseudohallucinations, or intensification of pareidolia, particularly auditory, are known side effects of opioids to different degrees—it may be associated with the absolute degree of agonism or antagonism of especially the kappa opioid receptor, sigma receptors, delta opioid receptor and the NMDA receptors or the overall receptor activation profile as synthetic opioids like those of the pentazocine, levorphanol, fentanyl, pethidine, methadone and some other families are more associated with this side effect than natural opioids like morphine and codeine and semi-synthetics like hydromorphone, amongst which there also appears to be a stronger correlation with the relative analgesic strength. Three opioids, Cyclazocine (a benzormorphan opioid/pentazocine relative) and two levorphanol-related morphinan opioids, Cyclorphan and Dextrorphan are classified as hallucinogens, and Dextromethorphan as a dissociative. These drugs also can induce sleep (relating to hypnagogic hallucinations) and especially the pethidines have atropine-like anticholinergic activity, which was possibly also a limiting factor in the use, the psychotomometic side effects of potentiating morphine, oxycodone, and other opioids with scopolamine
(respectively in the Twilight Sleep technique and the combination drug
Skophedal, which was eukodal (oxycodone), scopolamine and ephedrine,
called the "wonder drug of the 1930s" after its invention in Germany in
1928, but only rarely specially compounded today) (q.q.v.).
Sensory deprivation hallucination
Hallucinations can be caused by sensory deprivation
when it occurs for prolonged periods of time, and almost always occur
in the modality being deprived (visual for blindfolded/darkness,
auditory for muffled conditions, etc.)
Experimentally-induced hallucinations
Anomalous experiences, such as so-called benign
hallucinations, may occur in a person in a state of good mental and
physical health, even in the apparent absence of a transient trigger
factor such as fatigue, intoxication or sensory deprivation.
The evidence for this statement has been accumulating for more
than a century. Studies of benign hallucinatory experiences go back to
1886 and the early work of the Society for Psychical Research,
which suggested approximately 10% of the population had experienced at
least one hallucinatory episode in the course of their life. More
recent studies have validated these findings; the precise incidence
found varies with the nature of the episode and the criteria of
"hallucination" adopted, but the basic finding is now well-supported.
Non-celiac gluten sensitivity
There is tentative evidence of a relationship with non-celiac gluten sensitivity, the so-called "gluten psychosis".
Pathophysiology
Neuroanatomy
Hallucinations
are associated with structural and functional abnormalities in primary
and secondary sensory cortices. Reduced grey matter in regions of the superior temporal gyrus/middle temporal gyrus, including Broca's area,
is associated with auditory hallucinations as a trait, while acute
hallucinations are associated with increased activity in the same
regions along with the hippocampus, parahippocampus, and the right hemispheric homologue of Broca's area in the inferior frontal gyrus. Grey and white matter abnormalities in visual regions are associated with visual hallucinations in diseases such as Alzheimer's disease, further supporting the notion of dysfunction in sensory regions underlying hallucinations.
One proposed model of hallucinations posits that overactivity in
sensory regions, which is normally attributed to internal sources via
feedforward networks to the inferior frontal gyrus, is interpreted as
originating externally due to abnormal connectivity or functionality of
the feedforward network.[37]
This is supported by cognitive studies those with hallucinations, who
demonstrate abnormal attribution of self generated stimuli.
Disruptions in thalamocortical circuitry may underlie the observed top down and bottom up dysfunction.
Thalamocortical circuits, composed of projections between thalamic and
cortical neurons and adjacent interneurons, underlie certain
electrophysical characteristics (gamma oscillations)
that are underlie sensory processing. Cortical inputs to thalamic
neurons enable attentional modulation of sensory neurons. Dysfunction in
sensory afferents, and abnormal cortical input may result in
pre-existing expectations modulating sensory experience, potentially
resulting in the generation of hallucinations. Hallucinations are
associated with less accurate sensory processing, and more intense
stimuli with less interference are necessary for accurate processing and
the appearance of gamma oscillations (called "gamma synchrony").
Hallucinations are also associated with the absence of reduction in P50
amplitude in response to the presentation of a second stimuli after an
initial stimulus; this is thought to represent failure to gate sensory
stimuli, and can be exacerbated by dopamine release agents.
Abnormal assignment of salience to stimuli may be one mechanism
of hallucinations. Dysfunctional dopamine signaling may lead to abnormal
top down regulation of sensory processing, allowing expectations to
distort sensory input.
Treatments
There
are few treatments for many types of hallucinations. However, for those
hallucinations caused by mental disease, a psychologist or psychiatrist
should be consulted, and treatment will be based on the observations of
those doctors. Antipsychotic and atypical antipsychotic medication may also be utilized to treat the illness if the symptoms are severe and cause significant distress.
For other causes of hallucinations there is no factual evidence to
support any one treatment is scientifically tested and proven. However,
abstaining from hallucinogenic
drugs, stimulant drugs, managing stress levels, living healthily, and
getting plenty of sleep can help reduce the prevalence of
hallucinations. In all cases of hallucinations, medical attention should
be sought out and informed of one's specific symptoms.
Epidemiology
One study from as early as 1895 reported a much higher figure,
with almost 39% of people reporting hallucinatory experiences, 27% of
which daytime hallucinations, mostly outside the context of illness or
drug use. From this survey, olfactory (smell) and gustatory (taste) hallucinations seem the most common in the general population.
